A 30-day risk assessment of mastectomy alone compared to immediate breast reconstruction (IBR)

Abstract

Immediate breast reconstruction (IBR) is emerging as a favourable reconstruction option for breast cancer patients. Understanding the factors associated with complications following IBR will enhance care delivery, risk counselling and management, and potentially improve patient satisfaction. Women undergoing mastectomy alone and mastectomy with IBR from 2005–2011 were identified in the ACS-NSQIP datasets. Specific complications examined included surgical (flap or prosthesis loss and unplanned reoperation), wound (superficial/deep surgical site infection and wound dehiscence), and medical complications. Bivariate and multivariate analyses were performed to identify predictors of outcomes. A total of 47,443 patients were identified. For patients who underwent IBR compared to mastectomy alone, total complications (11.2% vs 9.2%, p < 0.001) and surgical complications (7.8% vs 4.7%, p < 0.001) were more frequent. In adjusted analysis, a common predictor of complications was class III obesity (BMI ≥ 40 kg/m²) for mastectomy alone (OR = 1.79, p < 0.001) and implant-based IBR (OR = 2.20, p < 0.001), and class II obesity (BMI 35–39.9) for autologous IBR (OR = 1.62, p = 0.003). Wound complications were found to be associated with autologous reconstruction (p < 0.001 kg/m²), smoking (p < 0.001), bilateral procedures (p = 0.005), patient comorbidity (p = 0.006), obesity (p < 0.001), and diabetes (p < 0.001). The strongest predictors of wound complications were class II obesity (OR = 2.12), class III obesity (OR = 3.09), and smoking (OR = 1.70). Risk factors for medical morbidity included: immediate autologous (p < 0.001), recent chemotherapy (p = 0.013), ASA physical status (p < 0.001), bilateral procedure (p = 0.002), patient comorbidity (p < 0.001), and obesity (p < 0.001). The strongest predictors of medical morbidity were immediate autologous reconstruction (OR = 3.54) and comorbidity burden of ≥2 comorbid conditions (OR = 2.28). In conclusion, undergoing IBR is associated with a modality-specific increased risk of morbidity relative to mastectomy alone. However, other modifiable risk factors appear to be strongly correlated with postoperative complications. Level of Evidence: prognostic/risk category, level II.

Key Words::

• Breast reconstruction
• implants
• outcomes
• ACS-NSQIP
• mastectomy
• risk

Declaration of interest

This particular research received no internal or external grant funding. The authors report no relevant financial disclosures related to this current work. De-identified patient information is freely available to all institutional members who comply with the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Data Use Agreement. The Data Use Agreement implements the protections afforded by the Health Insurance Portability and Accountability Act of 1996. The ACS-NSQIP and the hospitals participating in the ACS-NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors of this study. IRB/HIC exemption was approved by our institutions.